Every finding on record at Athena Hospice Services of Massachusetts

Based on record review and staff interview, the facility failed to maintain an Emergency Preparedness Plan (EPP) that was reviewed and updated at least annually. Findings include: --- Review of the agency's Emergency Preparedness Plan on 10/16/24 indicated that the last time the emergency plan was reviewed was on November 15, 2017, with an additional policy entitled Infection Control during a pandemic, dated December 2018. During an interview on 10/16/2024 at 1:00 P.M., the Quality Assurance Manager said that she was responsible for the Emergency Plan and the plan had not been updated since her coming to the agency 3 years ago. She also said she could not find any information as to when the plan was last reviewed and revised since November 2017.

Based on review of the agency's Emergency Preparedness Plan and staff interview, the agency failed to develop, establish, and maintain a comprehensive emergency preparedness program to comply with all applicable federal, state, and local emergency preparedness requirements, including the use of volunteers during an emergency. Findings include: --- Review of the Emergency Preparedness Plan on 10/16/24 indicated that there was no plan or policy in place for the use of volunteers during an emergency for the hospice agency. During an interview on 10/16/24 at 1:00 P.M., the Quality Assurance Manager said that there was no policy or plan in the Emergency Preparedness Plan to address the use of volunteers during an emergency.

Based on record review and staff interviews, the Hospice Agency failed to follow the plan of care relative to the frequency of visits by Skilled Nursing and Hospice Aides, for 5 patients (RR #1, RR #4, RR #6, RR #8 and RR #10), out of a total sample of 19 patients. Findings include: 1. For Patient RR #6, the Agency failed to follow the plan of care relative to Hospice Aide visits. Patient RR#6 was admitted to the agency in July 2024 with a primary diagnosis of hypertensive chronic kidney disease. Review of the current physician orders for the certification period of 8/23/24 - 10/21/24, indicated orders for Hospice Aide services 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care: - For the week of 8/25/24 - 8/31/24, only 2 Hospice Aide visits were conducted instead of the 5 as ordered. - For the week of 9/1/24 - 9/7/24, only 3 Hospice Aide visits were conducted instead of the 5 as ordered. 2. For Patient RR #8, the Agency failed to follow the plan of care relative to Hospice Aide visits. Patient RR #8 was admitted to the agency in June 2024 with a primary diagnosis of hypertensive chronic kidney disease. Review of the physician orders for the certification period of 6/26/24 - 9/25/24 and 9/26/24-12/24/24, indicated orders for Hospice Aide services 3 times per week for the certification period of 6/26/24-9/25/24 and Hospice Aide services 4 times a week for certification period of 9/26/24-12/24/24. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care: - For the week of 8/18/24 - 8/24/24, only 1 Hospice Aide visit was conducted instead of the 3 as ordered. - For the week of 9/1/24 - 9/7/24, only 2 Hospice Aide visits were conducted instead of the 3 as ordered. - For the week of 10/6/24 - 10/12/24, only 3 Hospice Aide visits were conducted instead of the 4 as ordered. 3. For Patient RR #10, the Agency failed to follow the plan of care relative to Hospice Aide visits. Patient RR#10 was admitted to the agency in June 2024 with a primary diagnosis of Alzheimer's dementia. Review of the current physician orders for the certification period of 8/4/24-10/2/24 and 10/3/24-10/15/24, indicated orders for Hospice Aide services 4 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care: -For the week of 9/15/24 - 9/21/24, only 2 Hospice Aide visits were conducted instead of the 4 as ordered. -For the week of 9/22/24 - 9/28/24, only 3 Hospice Aide visits were conducted instead of the 4 as ordered. -For the week of 9/29/24 - 10/5/24, only 2 Hospice Aide visits were conducted instead of the 4 as ordered. -For the week of 10/6/24 - 10/12/24, only 3 Hospice Aide visits were conducted instead of the 4 as ordered. 4. For Patient RR #1, the Agency failed to follow the plan of care relative to Hospice Aide visits. Patient RR#1 was admitted to the agency in August 2024 with a primary diagnosis of Alzheimer's dementia. Review of the current physician orders for the certification period of 8/7/24-11/4/24, indicated orders for Hospice Aide services 5 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care: -For the week of 9/1/24 - 9/7/24, only 4 Hospice Aide visits were conducted instead of the 5 as ordered. -For the week of 9/15/24 - 9/21/24, only 3 Hospice Aide visits were conducted instead of the 5 as ordered. 5. For Patient RR #4, the Agency failed to follow the plan of care relative to Skilled Nursing visits. Patient RR#4 was admitted to the agency in July 2024 with a primary diagnosis of Alzheimer's dementia. Review of the current physician orders for the certification period of 7/6/24-10/23/24, indicated orders for Skilled Nursing services 3 times per week. Review of the clinical record indicated that the following services were not documented as being provided in accordance with the plan of care: -For the week of 8/25/24 - 8/31/24, only 1 skilled nursing visit was conducted instead of the 3 as ordered. During an interview on 10/16/24 at 1:25 P.M., the Quality Assurance Manager said the agency leadership became aware of the lack of documentation pertaining to missed visits about a month ago, however they had not developed a formal PIP to address this concern. The expectation is if an aide was unable to make a visit, then they would contact the scheduler, who in turn would contact the case manager, who would write a note in the electronic medical record as to the reason for the missed visit.

Based on record review and staff interview, the agency failed to ensure that two Hospice Aides (HA) (#3 and #4) successfully completed a competency evaluation program, out of four sampled HAs . Findings include: 1. HA #3 was hired in August 2017. Review of her personnel file indicated there was an undated skills checklist in the file. During an interview on 1/4/22 at 4:45 P.M., the agency Administrator said she did not know why this checklist was not dated and could not confirm when this was completed without a valid date. 2. HA #4 was hired in March 2008. Review of her personnel file indicated there was no skills checklist completed upon hire. The skills checklist that was completed was dated 11/7/2011, a period of over three years after this aide was hired and began caring for Hospice patients. 3. During an interview on 1/4/22 at 5:00 P.M., the agency Administrator could not explain why the skills checklist was undated or why the checklist for HA #4 had not been completed for this HA for over three years after hire.